Young World Child Care & Learning Center Inc. Enrollment Agreement

Young World Child Care & Learning Center Inc. Enrollment Agreement

Completion of this agreement is required for enrollment. This form will enable us to better understand your child and meet his/her needs. Much of the information requested is necessary to comply with state child care licensing regulations.

Enrollment Information
If your child is participating in school age child care, please complete form titled, “School Age Child Care Supplemental Enrollment Form”
Child’s Information
Child’s first name / Child’s middle name / Child’s last name / Child’s nickname
Age / Sex / Child’s primary language / Parent/guardian/sponsor primary language
Child’s home address / City / State / Zip
Does your childattend school?
□ Yes □ No / School name / Grade / School phone
School address / Drop off time / Pick-up time
Family Information
List family members & pets your child lives with – include first names, relation and ages of siblings
Parent/guardian/sponsor / Relationship to child / Home phone / Cell phone
Home address if different from above / City / State / Zip
Home email / Work email / Work phone
Employer / Employer address / City / State / Zip / Work hours
Other parent/guardian/sponsor / Relationship to child / Home phone / Cell phone
Home address if different from above / City / State / Zip
Home email / Work email / Work phone
Employer / Employer address / City / State / Zip / Work hours
Child Emergency Contact and Release Information (do not include parents/guardians/sponsors)
Please notify the center if an Emergency Release Contact will pick up your child on a given day.
[For the safety of your child, we request that all authorized pick up persons with whom staff is not familiar provide a photo ID at the time of pick up.]
Person #1 / Relationship to child / Home phone / Cell phone
Home address / City / State / Zip
Home email / Work email / Work Phone
Employer / Employer address / City / State / Zip / Work hours
Person #2 / Relationship to child / Home phone / Cell phone
Home address / City / State / Zip
Home email / Work email / Work Phone
Employer / Employer address / City / State / Zip / Work hours
Person #3 / Relationship to child / Home phone / Cell phone
Home address / City / State / Zip
Home email / Work email / Work Phone
Employer / Employer address / City / State / Zip / Work hours

The persons designated in this section will be contacted by us if you cannot be reached in the event of a medical or other emergency. Our staff will only release your child to you or to those persons listed above. If you want a person who is not identified above to pick up your child, you must notify our staff in advance, in writing. Your child will not be released without prior authorization.

Parent initial ______Staff initial ______Date ______

Young World Child Care & Learning Center Inc. Enrollment Agreement

Medical Information
Child’s name / Birth date / Height / Weight / Hair color / Eye color
Distinguishing marks
Child’s Medical & Developmental History
1. Does your child have any special medical conditions? □ No □ Yes Explain
2. Does your child have any chronic illnesses? □ No □ Yes Explain
3. Please list a brief history of your child’s serious injuries and hospitalizations.
4. Does your child have diabetes? □ No □ Yes If yes, please attach care instructions from your physician.
5. Does your child have asthma? □ No □ Yes If yes, please attach care instructions from your physician.
6. Will medication be administered regularly? □ No □ Yes If yes, please attach care instructions from your physician.
7. Does your child have any special dietary needs? □ No □ Yes Explain
8. Is your child able to fully participate in all activities? □ Yes □ No Explain
9. Does your child have any physical restrictions? □ No □ Yes Explain
10. Does you child function at the level of other children in his/her age group? □ Yes □ No Explain
11. Is your child able to walk □ Yes □ No
12. Can your child communicate his/her needs? □ Yes □ No
13. Does your child need assistance at meal time? □ No □ Yes Explain
14. Does your child rest during the day? □ No □ Yes
15. Is your child toilet trained? □ No □ Yes
16. Does your child use any special equipment, such as breathing machine, wheelchair, hearing aid, braces, glasses etc? □ No □ Yes Explain
17. Does your child require on-to-one care/supervision on a regular basis for a significant period of time? □ Nor □ Yes Explain
18. Does your child require any accommodations or modifications to fully and equally enjoy and participated in a group care setting?
□ No □ Yes Explain
Illness History(please check all that apply)
□ Vision problems / □ Nosebleeds / □ Seizures
□ Hearing problems / □ Skin rashes / □ Mouth sores
□ Constipation / □ Sore throats / □ Fainting
□ Diarrhea / □ Ear infections / □ Persistent cough
□ Asthma/breathing problems / □ Urinary track infections / □ Other
Please attach care instructions from your physician for any of these illnesses.
Disease History(please check all that apply and add the date)
□ Chicken Pox (Varicella) / □ Bronchiolitis / □ Botulism
□ Measles Rubeola / □ Pneumonia / □ Haemophilus Influenza
□ Rubella (German Measles) / □ Pertussis (Whooping cough) / □ Meningococcal Infection
□ Mumps / □ Tetanus / □ Rabies
□ Scarlet Fever / □ Diphtheria / □ Bacterial Meningitis
Allergies(please list)
Medication Allergies / Reaction / Food Allergies / Reaction
Bee Stings Allergies / Reaction / Respiratory Allergies / Reaction
Other Allergies / Reaction / Are any of these allergies life-threatening? / □ Yes / □ No
Please attach care instructions from your physician for any life-threatening allergies...
Miscellaneous Screenings and Tests(please check all that apply and add the date of last screening)
□ Vision / □ Developmental / □ Tuberculosis (PPD)
□ Hearing / □ Aptitude / □ Sickle Cell Anemia
□ Speech / □ Educational / □ Other

To the best of my knowledge the information contained above is accurate.

Parent initial ______Staff initial ______Date ______

Young World Child Care & Learning Center Inc. Enrollment Agreement

Medical Information (continued)
Child’s name / Birth date
Child’s Medical Care Provider
Primary physician’s name / Primary physician’s practice name / Phone
Physician’s practice address / City / State / Zip
Preferred hospital/clinic for emergency care / City / State
Dentist’s name / Dentist’s practice name / Phone
Dentist’s practice address / City / State / Zip
Child’s Insurance Provider
Child’s health insurance provider name / Policy number / Secondary health insurance provider name / Policy number
Child’s Immunization History(please attach a copy of your child’s immunization records)
Below is a list of immunizations that your child may have received. Immunizations in bold are required by our state. [Check with your state requirements. You may do this at Bold any immunization below that is a requirement.]
Anthrax / Influenza / Pneumococcal disease / Smallpox
Diphtheria / Lyme Disease / Polio / Tetanus
Haemophilus Influenzae type b (Hib) / Measles / Rabies / Tuberculosis
Hepatitis A / Meningococcal disease / Rotavirus / Typhoid Fever
Hepatitis B / Mumps / Rubella / Varicella (Chickenpox)
Human Papillomavirus (HPV) / Pertussis (Whooping Cough) / Shingles (Herpes Zoster) / Yellow Fever
Additional Medical Policies
1. Prior to enrollment, I must provide the center with updated medical and immunization information for my child. This information is to be kept current and updated in accordance with state child care regulations. / Initial
2. I agree to provide information to the child care center about my child’s conditions, illnesses, allergies or other needs.
3. If my child becomes ill with a reportable contagious disease, I understand that he/she will not be able to return until I bring in a physician’s note stating that he/she is no longer contagious.
4. If my child becomes ill during his/her time at the child care center, the staff will contact me to pick up my child. I will arrange for pick up as soon as possible and no later than 2 hours after being contacted. If I cannot be reached, the staff will contact those listed in the Child Emergency Contact and Release.
Emergency Medical Authorization & Consent
In case of a medical emergency, the staff will attempt to contact me, those listed in the ChildEmergency Contact and Release, and lastly my physician. / Initial
In case of a medical emergency, I agree that my child may receive first aid and/or CPR.
In case of a medical emergency, I permit the transportation of my child to a local hospital or other urgent care facility, if necessary by paramedics or other emergency personnel.
In case of a medical emergency, I will be responsible for the emergency medical expenses.
In case of an accidental ingestion of a poisonous substance, I consent to my child being treated as directed by the PoisonControlCenter.
I give my permission to this center to apply □ sunscreen and □ insect repellant to my child. Please check which product you will permit. / Initial
I understand that I must supply my own sunscreen and/or insect repellant with a valid expiration date, and it will be labeled with my child’s name.
I have special instructions for the application process. □ None □

Parent initial ______Staff initial ______Date ______

Young World Child Care & Learning Center Inc. Enrollment Agreement

Rate Agreement and Contract
Child’s name / Birth date
Hours of Operation
Regular operating hours are Monday through Friday from7:00 AM to6:00 PM except closings for various holidays, and inclement weather as described in the Family Handbook. Please consult the current calendar for holidays. There is no reduction in tuition as a result of center closures.
The procedure to notify families should severe weather or other conditions prevent the program from opening on time or at all will be announced on radio station ______. If it becomes necessary to close early, we will contact you or someone listed in the Emergency Contact and Release, and it will be your responsibility to arrange for your child’s early pick up.
Scheduled Attendance
The days and hours that I wish to contract for child care are as follows:
Day of week / Start time / AM/PM / End time / AM/PM / Comments
Monday
Tuesday
Wednesday
Thursday
Friday
I would prefer to make tuition payments on a / □ weekly / □ bi-weekly / □ monthly / basis.
Fee Policy(to be completed by staff; reviewed and initialed by the parent/guardian/sponsor after completion)
- Starting on ______a fee of$______ is due / □ weekly.
□ bi-weekly.
□ monthly. / Initial
- Tuition is due and payable on the / □ first business day of the week.
□ the 1st and 15th of the month or next business day.
□ first business day of the month.
- Tuition is not subject to discounts for holidays, emergency closures (i.e., weather), or absence other than hospitalization, contagious illness, or absence at the request of a doctor (a written doctor’s note is required to receive credit).
- I agree to pay the full tuition in advance of services rendered.
- I agree to pay the full tuition fee even if my child is absent for one or more days.
- A late fee of $_____ is due if tuition is not received on time.
- A non-refundable registration fee of $_____ is due yearly.
- A late pick-up fee of $_____ per minute per child (not to exceed $_____ per child) is due if my child is not picked up before closing.
- Accounts two weeks in arrears may result in immediate termination of service.
- My child may have the opportunity to participate in a special program or field trip that may have an additional fee due before the day of the event. A specific permission slip may be required.
- All returned checks or ACH transactions (automatic debits) will be charged a fee up to the maximum amount allowed by law. Two or more returned checks or ACH transactions will result in my account being place on “money order only” status.
- A receipt for income tax purposes □ will □ will not be provided.
Other Agreements
Private Employment Acknowledgement and Release
Any arrangement/employment between me and staff of this center (i.e., babysitting), outside of the programs and services offered by this center, is an individual endeavor and private matter not connected or sanctioned by this center. This center shall remain harmless from any such arrangement. / Initial
Media Release
Occasionally, photos will be taken of the children at the center for use within the center or on our website. Please indicate that you authorize the use and reproduction of photographs of your child in conjunction with the program. / Initial

Parent initial ______Staff initial ______Date ______

Young World Child Care & Learning Center Inc. Enrollment Agreement

Other Agreements(continued)
Child’s name / Birth date
Walking Excursions
I give my permission for my child to participate in supervised walking excursions near and around the center. / Initial
Handbook Acknowledgement
I understand and agree that it is my responsibility to read and familiarize myself with policies and procedures outlined in the Family Handbook and agree to abide by them. / Initial
I understand that it is my responsibility to go directly to management with any questions I may have regarding the policies and procedures and information contained in this Enrollment Agreement.
Information contained in the Family Handbookmay be subject to change.
Contract Approval
I certify that I have read, understand, and accept all of the terms and conditions described in this EnrollmentAgreement and the Family Handbook.
Primary Parent/Guardian/Sponsor Signature / Date / Center Staff Signature / Date

School Age Child Care Supplemental Enrollment Form

Enrollment Information
Child’s Information
Child’s first name / Child’s middle name / Child’s last name / Child’s nickname
Age / Sex / Child’s primary language / Parent/guardian/sponsor primary language
Child’s home address / City / State / Zip
Does your child attend school?
□ Yes □ No / School name / Grade / School phone
School address / Drop off time / Pick-up time
Child will be attending: □ Morning Care □ Afternoon Care
My Child is allowed to walk (3rd grade and older*): □ To School from Child Care □ From School to Child Care
*Note: [Child care center name] is not liable for the child until he/she arrives at the program or after the child has left the program to walk to/from school.

After School Activities Information

Completethe information below to provide us with details about after school activities your child is participating in. Please complete a separate Transportation and School Activity form for each activity.

Transportation and After School Activity
My child is transported to school via: / My child is transported from school via: Bus #:
Parents are responsible for informing child care center in writing if your child(ren) will be participating in an after school activity:
Child participates in the following after school activities (list all):
Type of Activity:
Day of the week child is attending activities (circle all that apply): M T W Th F
Time period of activity:
Day:
Start Time:
End Time: / Day:
Start Time:
End Time: / Day:
Start Time:
End Time: / Day:
Start Time:
End Time: / Day:
Start Time:
End Time:
Name of authorized person to pick up / drop off your child for the extracurricular activity:
Transportation and After School Activity
My child is transported to school via: / My child is transported from school via: Bus #:
Parents are responsible for informing child care center in writing if your child(ren) will be participating in an after school activity:
Child participates in the following after school activities (list all):
Type of Activity:
Day of the week child is attending activities (circle all that apply): M T W Th F
Time period of activity:
Day:
Start Time:
End Time: / Day:
Start Time:
End Time: / Day:
Start Time:
End Time: / Day:
Start Time:
End Time: / Day:
Start Time:
End Time:
Name of authorized person to pick up / drop off your child for the extracurricular activity:

Your child’s safety is our number one priority. [Child care center name] will not release children from the program without the above information in writing.

______

Parent / Guardian Signature Date